Hip and Thigh

Avascular Necrosis

• When the bone is not properly supplied with blood, that part will die and healing won't take place

• Femoral head can loses its rounded shape and won't rotate smoothly within the acetabulum, it can lead to a form of arthritis

Movement of Hip

• Flexion or extension

  • 120 degrees

• Adduction and abduction

  • 50 degrees of abduction

• Internal and external rotation

  • 45 external

  • 35 internal

Bones in the Hip

Femur, pelvis, Ischium and pubis

Pelvic bone

• Anterior Superior Iliac spine (ASIS)

• Anterior Inferior Iliac Spine (AIIS)

• Iliac crest

Pubis Bones

ramus and Symphysis

Articulations

The head of the femur articulates with the acetabulum, which is lateral to the pelvis. there is depth which allows it to encompass almost the entire head and its deepened by the peripheral labrum.

It is a ball in socket joint and a Synovial joint, it ahs a capsule

Labrum

• Ring of touch cartilage around the acetabulum

• It distributes force and holds on to the head of the femur

• Cushions joint

Foveal artery

• artery Runs inside the ligament to the femoral head

• Helps avoid avascular necroses,

Posterior ligaments

Ischiofemoral

Anterior Ligament

Illiofemoral and Pubofemoral

Bursae

• Iliopsoas

  • Between the iliopsoas muscle and anterior joint capsule

• Trochanteric

  • Between the greater trochanter of femur and gluteus maximus muscle

Sprain and Strain

Hx

• Violent torsion or extension

• Hip flexion against resistance

  • Iliopsoas strain

Ssx

• Deep pain, worse with movement

• Pain with AROM, no pain with Passive

Tx

• Rest, NSAID, physiotherapy

Subluxation

• Sublux is seen in extreme ROM sports

  • Femoral heads comes out of acetabulum and pops back in

  • Gymnastics, dancing martial arts

  • Narrow pelvis, abnormal increase in abduction ROM, lack of ROM in internal and external ROM

  • Cause by acetabulum labral tears and sublux of the joint itself

  • Relatively harmless

  • Often chronic

    • Could lead to osteoarthritis

  • Tx for sublux

    • Rest, ice, NSAIDs, stretching , change activities

Snapping hip

• Tendon slides over the trochanter

  • Iliotibial slides over the greater trochanter

  • Iliopsoas slides over lesser trochanter

Hip Dysplasia

• Femur head id deformed and has a shallow hip socket

• Allows for the hip joint to become partially or completely dislocation

• Can be curable in childhood

• Laeds to arthritis later in life

Bursitis

• Hx

  • Overuse or direct blow

• Ssx

  • Tenderness, pain on movement

• Tx

  • POLICE

  • NSAID

  • Rest

  • Physio

Labral Tear

• Hx

  • Shearing

  • Excessive forces at hip joint

    • Internal rotation

  • Hip labrum pulls away from acetabulum

• 3 main causes

  • Trauma, motor vehicle accidents

  • Hip abnormalities

    • Hip dysplasia, FAI

  • Repetitive movements, most common

    • Twisting, hockey/golf

    • Extreme end range, ballet and gymnastics

    • Repetitive joint loading, marathoners

• Ssx

  • Deep groin/buttock pain

  • Pain/stiffness moving hip in certain directions

  • Feeling clicking/locking when moving hip joint

• Tx

  • Conservative

    • Rest, NSAIDS, injections, physiotherapy

  • Surgical

    • Arthroscopic labral debridement

    • Arthroscopic labral repair

    • Arthroscopic labral replacement

  • Labral tear predisposes athlete to articular cartilage degeneration or osteoarthritis

Fracture/Dislocation

• Hx

  • Severe Trauma (MVA) or elderly person (Neck of femur)

• Ssx

  • Extreme pain, markedly reduced ROM deformity, it may not be present

• Tx

  • Recognize, stabilize and transport

  • NPO cause surgery

  • Avascular necrosis can be a complication

    • Fracture can damage blood vessels and reduce blood flow to bones

Thigh Bones

• Femur

  • Head

  • Neck

  • Greater and lesser trochanters

  • Shaft

  • Condyles

Thigh Arteries

Artery

• Femoral

• Turns to popliteal

Thigh Nerves

• Femoral

  • L2 to L4 nerve root

• Sciatic

  • L4 to S3 Nerve root

Hip Flexors

• Iliopsoas

  • iliacus

• Rectus femoris

Hip Extensors

• Gluteus maximus

•  hamstrings

Hip Adductors

• Adductors

  • Magnus

  • Longus

  • Brevis

• Gracilis

• Pectineus

Hip Abductors

• Gluteus medium, minimums, maximus

• Tensor fascia latae and others

Hip External Rotators

• Piriformis

• Obturator externus and internus

• Superior and inferior gemellus

• Quadratus femoris

Hip Internal Rotators

• TFL, tensor fascia latae

• Gluteus Medius

• Adductors

• pectineus

Piriformis

• Underneath the gluteus maximus, right above the sciatic nerve

• If it is tight it can pinch the sciatic nerve

Iliotibial Band

• A lateral thickening of the fascia latae

• Cord of connective tissue

• Source of pain is from the richly innervated and vascularized layer of fat and connective tissue between the IT band and lateral epicondyle

Anterior Compartment

• Quad Muscle group

  • Primarily knee extensors

  • Rectus femoris

  • Vastus lateralis

  • Vastus intermedius

  • Vastus medialis

Posterior Compartment

• Hamstring muscle group

• Primarily knee flexors

• Biceps femoris

  • Most lateral

• Semitendinosus

  • Middle of hamstring group

• Semimembranosus

  • Most medial

Medial Compartment

• Adductor muscle groups

• Adductor magnus, longus, brevis

• Pectineus

• Gracilis

Contusion

• Hx

  • Direct blow

• Ssx

  • Pain and bruising

  • Tenderness/firm on palpation

  • Localized swelling

  • Decreased ROM

  • Limp

• Tx

  • POLICE

  • NO HEAT NO MASSAGE over the contusion

  • Padding

  • ROM exercise and physio

Myositis Ossifications

• Several contusions or mishandling or severe contusion

• ROM not returning after contusion

• Thigh firm on palpation weeks to months later

• Send of imaging

• Bone is being laid down within the injured muscle

• Can be causes heating and massaging over the contusion

Strain

• Hx

  • Resisting a force, torsion, hyperextension, abduction

  • Predisposed by decreased strength or flexibility, previous strains

• Ssx

  • 1st degree

    • Pain (worse with resistance and AROM)

    • Tenderness

    • No limp, snap or pop

  • 2nd degree

    • Pain and tenderness, bruising

    • Snap or pop felt/heard

    • Limp

  • 3rd degree (rupture)

    • Pain and tenderness, bruising

    • Snap or pop felt/heard

    • Limp

    • Gap in the muscle

• Tx

  • 1st degree

    • POLICE

    • ROM exercise, tape

  • 2nd degree

    • POLICE

    • Rest for 2-6 weeks

    • ROM exercise, tape

    • Physio and rheab

  • 3rd degree

    • NPO, stabilize

    • Transport to hospital for surgery

    • Rest, physio, rehab

Hamstring Strain

Cause

• Inflexibility

• Improper warm-up

• Temperature

• Fatigue

• Violent contraction

Tx

• POLICE, rest, stretching delayed, strengthening eccentric, gradual return to activities, hamstring tensor wrap and core shorts

Iliotibial band Friction Syndrome

• Clinical features

  • Subjective; ache on lateral aspect of the knee

  • Worse with cycling downhill running

• Objective

  • Tenderness on palpation over lateral femoral epicondyle

  • Positive Ober's test

    • With or without burning sensation

  • Tightness of gluteus max and TFL

    • Over developed vastus lateralis

    • Overprotection can increase tibial rotation

    • Increase in femoral rotation/genu valgum

• Treatment

  • Pathology is distal but need to treat proximal

  • Exercise therapy similar to patellafemoral pain syndrome

    • Strengthen hip abductors

    • Release glute max/TFL/ Vastus lateralis

    • Soft tissue release, massage, foam rolling, stretching

      • Dry needle

Fracture

• Femoral fracture

• Major trauma

• Ssx

  • Severe pain, inability to weight bear

• Tx

  • Stabilize NPO, get to hospital ASAP

• Surgery with internal fixation with rod and plate

• Rehab: gradual progression of ROM and strengthening/progressively weight bearing over 4-6

Scrotal Contusion

• Direct blow or trauma to the scrotum

• Pain subsides over 5 minutes

• Tx: hip flexion and gentle breathing

Traumatic Hydrocoele

• Delayed complications of contusion (days, weeks, months)

• Appearance of cluster or swollen veins

• Tx: surgical if warranted

Torsion of Spermatic Cord

• Pain increase over time

• Nausea, vomiting

• Shock, rapid HR and RR; clammy skin

• Swelling and extreme tenderness

• Surgical emergency

• NP and transport ASAP

Hip Pointer

• Contusion of iliac crest

• Ssx

  • Pain, tenderness, bruising

  • Localized swelling, limp

  • Difficulty with flexing thigh or rotating trunk

• Tx

  • ICE, rest padding, physio

Coccygeal contusion

• Direct blow (fall, kick)

• Ssx

  • Pain, bruising, tenderness

• Tx

  • Hospital for X-ray

  • NSAID, warm baths

  • May need surgery